Hawaiian elder care professionals improve patient eldercare services to Japanese nationals, taking into consideration Japanese cultural norms and expectations

Caregiving for elderly parents in Japan

Japan has witnessed a significant growth in its elder population. In the year 1950, 4.9% of the Japanese population was aged 65 years and above. This figure increased to 14.8% (1995). By 2025, it is estimated to grow to 25.8% (Yamamoto & Wallhagen, 1997). Japan’s ‘very old’ population group (aged 85 and above) is swiftly increasing in number. It has been projected that by 2025, the nation’s ‘very old’ population will account for 4.3% of its total population — a five-fold rise in three decades. Furthermore, it was projected that as many as 2.62 million Japanese would be suffering from senile dementia by the year 2015; the 1990 estimate for senile dementia was about one million individuals (11WSA 1996).

Change in the percentage of Japan’s aged population has also brought with it a corresponding change in Japanese social norms pertaining to family issues. Historically, elder care in Japan was regarded as the predetermined duty of the successive generation in patrilineal extended families. Owing to this tradition, even in the year 1992, as many as 33.4% of aged, bedridden Japanese who weren’t sent to institutions were taken care of by their children’s spouses (Yamamoto & Wallhagen, 1997). The above moral tradition was financially strengthened by means of primogeniture, wherein main family assets went to the male heir upon his father’s demise. But following the Second World War, a newly-passed legislation on inheritance abolished the primogeniture tradition. Hence, despite the time-honored moral imperative continuing to strongly influence involved individuals, the actual operation of this familial duty is now changing gradually. For instance, Japanese households with three generations of the family reduced from to 12.5% (1995) from 19.2% (1970). The above modification to family configuration will likely significantly change Japanese views on family caregiving to aged persons.

Another key element relating to Japanese parental caregiving is women’s role in the traditional Japanese family. Elderly and patient care was traditionally a role expected to be performed by the women in the household (Yamamoto & Wallhagen, 1997). As per the traditional Japanese cultural rule, the wife of the heir (first son) is required to care hands-on for his aged parents. This includes changing their diapers, feeding them, etc., until the aged person(s) gets hospitalized due to a medical condition. However, of late, this age-old role expectation might be a cause of conflict for Japan’s growing number of working women. In the year 1975, roughly twelve million Japanese women held jobs, whereas by 1993, this figure had increased to twenty million (Yamamoto & Wallhagen, 1997).

With more widespread acknowledgement, in Japan, of the problem of a growing share of aged individuals requiring assistance with their everyday activities, a number of formal services were launched. In the year 1990, a “Gold Plan” (an exclusive ten-year plan) for improving support for aged individuals and family members was executed. This Plan entailed the launching of daycare facilities, homecare support facilities, and development of facilities for long-term patient care. The Japanese Health and Welfare ministry planned to bring about a roughly-tenfold increase in these services from 1990 to 2000 (Yamamoto & Wallhagen, 1997). However, family support for people with demented, aged parents continues to be limited. If possible, these services must be extended to demented, elderly individuals and families. In fact, behavioral issues displayed by aged individuals diagnosed with dementia usually exclude this group from services like “short-stay” and day care arrangements. Also, the services offered are far less than what is required in Japan. Consequently, aged persons and their familial caregivers who require assistance are made to wait long (Yamamoto & Wallhagen, 1997).

In spite of their success, the long-term and health care structures of Japan experience sustainability problems similar to those faced by their U.S. counterparts, including increasing demand and mounting expenditure. The government of Japan is weighing up and pursuing numerous options, like: preventive services; increasing premiums, fees, or taxes; and promoting community-based healthcare services (Belli, 2013). The year 2011 saw the implementation of reform focused on the holistic model of community care. Slightly similar to a responsible care institution, such a model would guarantee access to hospital, medical, or long-term patient care, preventive services, legal services or life support, and residential care services within elderly people’s communities (Belli, 2013). Attention to service consolidation and prevention will, with any luck, reduce the use of costlier services, as it would ensure the population remains fitter.

1.2. Japanese vs. American elderly care

Professionals in the field typically look to Japan as an example of a nation that effectively handles its swiftly aging population’s needs. Its long-term and health care systems, though in no way absolutely perfect, provide aged Japanese with holistic, economical care. As the U.S. endeavors to implement healthcare reforms for controlling expenses and shifting focus to preventive and managed care, Japan has a few recommendations to put forward (Belli, 2013). While a nation’s healthcare structure is not solely responsible for shaping its population’s health, it can contribute to altering the population’s outlook towards health via the services on offer. Rather than following an exclusively acute health model, American healthcare is gradually migrating towards chronic disease management, prevention and long-term patient care. Aside from reducing costs, this type of shift can aid individuals in living healthier longer.

Some life expectancy disparities between Japan and the U.S. may be accounted for using health indicators. The U.S. obesity rate features on the list of the world’s highest (35.7%), whereas Japan’s obesity rate is one among the lowest (3.1%) (Belli, 2013). Obesity raises risks for several chronic ailments like diabetes, heart disease and hypertension. Further, America’s diabetes incidence is more than that of Japan. Smoking constitutes another factor (Belli, 2013). While Japan’s current smoking rate is higher than that of the U.S., traditionally, it was the reverse. On account of the prior high smoking rate in the U.S., life expectancy of Americans is now approximately a couple of years less (Belli, 2013). Apart from health influences, cultural values impact the aging population as well. Japan’s working population is one among the longest globally, thus older adults are able to support themselves for longer. Further, their strong social and family networks suggest that families deliver much of elder care. However, this trend is changing with Japanese society’s modernization.

While Japan and the U.S. experience similar challenges with regard to an increasing aging population group, the two nations have adopted different approaches to meet this population’s needs. Historically, the American healthcare structure emphasized acute care, and dealt with diseases as they surfaced, instead of concentrating on disease prevention or management. The rise in incidence of chronic diseases necessitates long-term social and medical services for more individuals, especially older adults, to help them manage their conditions. A large number of chronic ailments can be prevented via healthy lifestyle behaviors (e.g., regular exercise and healthy eating) (Belli, 2013). While U.S. healthcare insurance is still not available to all, nearly a half-century ago, the nation’s government recognized elderly people’s unique needs and launched its Medicare initiative. Currently, Medicare covers nearly all adults aged 65+, and some supplement the services not covered by Medicare through private insurance (Belli, 2013). Furthermore, almost 17% are entitled to Medicaid coverage. But Medicare is not all-inclusive, or even free, and this creates care gaps when patients are unable to find appropriate services or are unable to afford them.

Moreover, while Medicare covers nearly every aged American adult, its focus is acute care. The means-tested Medicaid initiative for people with low incomes belonging to all age groups covers long-term as well as acute care. A number of aged individuals also supplement Medicare with private insurance. Medicaid and Medicare are highly costly ventures, and cost over 900 billion dollars in the year 2010. The initiatives demand cost-sharing by all except the poorest beneficiaries, and their out-of-pocket expenditures are mounting (Belli, 2013). Aside from mounting healthcare spending, long-term and health care structures for the elderly are complicated and fragmented. Patients probably have no clue regarding the services that are available, services for which they are entitled, and who disburses their hospital bills. Inadequate communication typically ensues between patients’ service providers, but this may be mitigated through case managers’ aid. Also, family caregivers might not have adequate support. In case of elderly individuals suffering from chronic ailments and disabilities, this complex framework hampers their ability of receiving prompt and appropriate care.

Obamacare offers a few solutions like enhancing care coordination by adopting the EMR (electronic medical record) system, providing healthcare professionals with financial incentives for delivering the right care the very first time, and covering elderly persons’ preventive services (Belli, 2013). However, unlike American citizens, every citizen of Japan enjoys healthcare coverage. They are covered under a compulsory employment-based or “community-based” scheme — the latter entails insuring of citizens and residents not covered under the former system, by municipalities. Exceptions to the above systems are individuals aged above 75 years, covered under the prefecture-funded system, and poverty-ridden individuals, whose healthcare expenses are borne by the Public Assistance system (Belli, 2013). The schemes are financed via a “pay-as-you-go” structure, with a total of three financing streams: co-payments or user fees, insurance premiums, and general tax revenues (Belli, 2013). Insurers fix insurance premiums on the basis of numerous factors, like healthcare services usage and average earnings.

Japan’s national government establishes fee schedules for products and services (equipment, medicines, etc.), which are fairly consistent across the nation. Earmarked tax proceeds cover a few deficits in insurance covering the comparatively lower-income population (e.g., small firm employees, elderly persons, self-employed individuals, and part-timers) (Belli, 2013). User fees and premiums are different for different income levels, thereby making healthcare fairly affordable for the majority of the population. Moreover, government-established rates control healthcare spending, which is roughly 9.3% of Japan’s gross domestic product (GDP), against America’s 17.9% (Belli, 2013).

1.3. Patterns of Long-Term Care Use Among Japanese-Americans

In spite of its age-old family caregiving custom, Japanese families residing in Japan as well as the U.S. are now encountering challenges similar to those encountered by other populations — increasingly fewer caregivers are available because of greater geographic mobility and participation in the workforce (Young, McCormick & Vitaliano, 2002). Thus, for Japanese families residing in both nations, formal services have become an increasingly important alternative. Japan’s national government is employing its long-term “Gold Plan” for promoting welfare and health of elderly patients in the nation’s long-term patient care system, with increased participation among the elderly and family members in formal health services.

Japanese research has revealed the influence of cultural factors on usage of formal services. A qualitative research conducted in 1998 by Wallhagen and Yamamoto on family caregiving in Japan isolated three aspects that impact family decision to go for formal services: service availability, whether the primary caregiver is able to justify her level of tolerance to other members of the family, and caregiver’s authority in the family. The first dimension encompassed elements of distance, service quality, potential sanctions, quantity, and knowledge of available services. The dimension of tolerance level encompassed social caregiving customs, personal beliefs concerning how care ought to be delivered, and type of bond with patient. This research work shed light on the intricate interaction between influencing factors, in addition to caregivers’ careful negotiation when making service decisions (Hashizume, 2000). Hashizume’s (2000) review of the newly emerging gender-related problems for Japanese women considered Japanese cultural significance of privacy; their apprehension towards the presence of service providers at home, and their unwillingness to bear the associated embarrassment; strong cultural expectations for familial caregiving; and a feeling of having failed one’s responsibilities by relinquishing them to others.

Prior work among Washington’s Nikkei or Japanese-Americans has proven that in spite of Japanese stereotypes with respect to family caregiving, nursing homes produced a degree of interest that was similar to that created in the general U.S. population; this suggests the changing attitudes of Japanese families toward this alternative. But a new family caregiver survey revealed that Asian-Americans were the lowest users of community supportive services (like delivered meals, personal care, or day care for adults). A scant 15% of Asian households availed themselves of nursing or personal services, which represented about 50% of the rate for other cultural/ethnic groups. Additionally, a large number of participants (49%) stated they were unaware of what sort of information or assistance could prove valuable, as compared to 38% participants overall reporting they had no knowledge (Young et al., 2002).

There is, at present, only one culture-specific U.S. social service body, the JASC – Japanese-American Service Committee — which targets the Nikkei ethnic group’s elderly population residing in greater Chicago’s urban localities, and a medical clinic — Nihon Clinic — that is situated in a Chicago suburb, and reaches out expressly to expats from Japan (Lau, Machizawa & Doi, 2012). Having been of adequate service to American Nikkei for more than 65 years through its prompt responses to the community’s evolving needs, JASC aims at better understanding the use of formal and informal support among the functionally independent elderly Nikkei, for maximizing their chances of “aging in place” (i.e., continuing to remain at home and within one’s community in old age) (Lau, Machizawa & Doi, 2012, p.151). It has teamed up with the Chicago School of Professional Psychology and the UIC (University of Illinois at Chicago), for the purpose of carrying out a participatory community-based study for assessing the specific service requirements of elderly Nikkei residing alone in Chicagoland (i.e., suburban and urban Chicago) (Lau et al., 2012).

1.4. Factors Influencing Long-Term Care Use

There is a substantial pool of research on factors that influence nursing home usage. Various major variable factors have been recognized, including care receiver as well as caregiver traits predictive of an intent to institutionalize and actual nursing home placement (Young et al., 2002). Combined with the growth of community-based non-institutional health services, increasing attention has been paid to predicting usage of such formal service alternatives. Care recipient aspects that predict formal home care include living arrangements and an increased need for ADL (activities of daily living) aid; individuals hailing from smaller families and from senior housing employ paid assistance more frequently (Yamada, 2001). Additionally, those who are older, females, and hospitalized in the past year are expected to utilize these services more, while more family care hours reduces likelihood of seeking paid assistance. Numerous caregiver-related variables also prove vital in predicting use of formal services, such as the need for rearranging work hours, bladder and bowel care provision, and difficulties associated with making one’s way around outside of the house.

The acknowledgement of cultural influences in healthcare service patterns has given rise to several researches that have examined usage among diverse ethnic groups. Elderly Latinos exhibit patterns that are in line with those of the mainstream American population, including higher visiting nurse usage; medical care usage in the previous year; Medicaid eligibility; low income; home health assistants; homemakers needing more ADL; greater age; kids living far off; ancestry; and living alone (Yamada, 2001). Notably, this research failed to validate effect of acculturation in predicting use of services. In a group comparison, ethnicity emerged as a major predictor in utilization — elderly Hispanics utilized community-based health services more, while elderly Caucasians were associated with more homecare service utilization (Young et al., 2002). Elderly African-Americans showed greater inclination for home health care compared to elderly Caucasians, and this influenced discharge disposition patterns following acute hospitalization.

The resolution to avail oneself of formal services entails multifactorial and complex decision-making which unfolds with time. King, Collins, Given, and Stommel (1991) pinpointed reasons for people not utilizing formal services. These include an obligation to offer total care, an inclination to opt for informal, rather than formal, patient support, cultural expectations, dislike for relinquishing control of one’s home and family member (patient) to strangers, and concerns regarding community service quality. Instrument creation and testing for gauging views towards formal community service followed five aspects of influence amid the subscales: faith in the health service system; concern for others’ opinions; government service acceptance; faith in the independence of the caregiver; and desire to continue informal care. The last represents the greatest predictor of service usage.

1.4.1. Attitudes Toward Long-Term Care Services

Since people having similar health and functional needs may be dealt with in diverse settings, views and feelings toward services will likely be a further factor in the decision-making process, beyond situational caregiving characteristics. As applied in the reasoned action theory, attitudes are a variable that relate to salient beliefs held by a person with regard to an action; these may result from direct experience, inference, or via information received from others (AARP, 1984). The rural elderly holds different attitudes towards health services compared to the elderly population in urban localities, and this influences usage patterns. Understanding these attitudes underlying choice of health service increases recipients’ program acceptability. A large-scale AARP survey conducted in 1984 found 80% of its members preferring care at their own home over care at nursing homes (AARP, 1984). The following general observations were made: (a) Elderly individuals like avoiding nursing home services if they can; (b) They desire not to have their relatives’ lives disrupted (despite their relatives being ready to assist them, and considering it their responsibility), and (c) They are ready to accept sponsors (i.e., welfare) for paying their long-term care bills (AARP, 1984). Yet, not much is known about ethnic subpopulations’ attitudes towards individual program characteristics among different community long-term care options.

In the year 1993, the Nikkei LTC (Long-Term Care) initiative commenced an examination of healthy elderly Japanese-Americans’ views towards long-term medical/social care (Ajzen and Fishbein, 1980). This study has verified their readiness to consider home care as well as nursing homes, especially those services offered within their community. Over the last twenty-five years, local Nikkei have delivered formal services to their elderly members (including assisted living, meals, nursing home, and adult daycare). Providing such services, with voluntary community support and within community boundaries, has made the community regard these services as nothing more than an addition to the family caregiving tradition (Ajzen and Fishbein, 1980). Besides assessing longitudinal data pertaining to caregiver characteristics and cognitive and functional status, views and preferences with regard to long-term care have been assessed as well, by employing Fishbein and Ajzen’s (1980) model for understanding societal behavior. The Nikkei study aimed at supplementing the quantitative data already gathered and exploring, in depth, people’s attitudes and preferences with regard to specific services for individual communities.

1.5. Service Needs for Foreign-Born Caregivers and Care recipients

The absence of culturally-sensitive/applicable services constitutes an obstacle, particular for foreign-born or migrant care recipients and providers. Every year, new waves of migrants surge to American shores (Sato, 2015) — this group of people typically struggles with adapting itself to the novel culture surrounding them (McLaughlin, 2002). Specifically, foreign-born migrants (regarded as a particular lineage’s first generation), are inclined to stick to their native culture’s traditions, values, and beliefs, even after migrating to America. For example, the Issei (first-generation Japanese migrants to America), typically followed their own ethnic practices instead of adopting Western ones. The Issei, particularly on contiguous U.S.A., commonly struggle with linguistic barriers when it comes to seeking social services or information.

Thus, in the 60’s and 70’s, Issei-focused nursing facilities and community long-term social and health care services were planned to cater to their needs, in San Francisco, Seattle and Los Angeles (Keiro Senior HealthCare, n.d.). Second generation Japanese (and succeeding generations) may have different needs compared to their antecedents, as they will more likely reflect mainstream American culture. The above fact is applicable to other ethnic or racial minorities too. As a majority of research works into service utilization have been performed in the English language, migrant care recipients and providers have linguistic barriers that will be introduced into the study. Hence, little is known of their needs (Keiro Senior HealthCare, n.d.).

1.6. Asian and Japanese Cultural Factors Influencing Family Caregiving

Healthcare encompasses elements like ethics, patient-family ties, and patient-provider interaction. Previous studies indicate that the above three aspects greatly affect elderly Asian-Americans’ healthcare. Ethno-gerontologists have scrutinized the phenomenon of aging for Japanese culture, due to strong familial support for aged members. Family support in this culture is partially derived from their longstanding extended family style and partially because of the familial piety concept in Japanese religious tradition (Yamada, 2001).

Behavioral science groups Japanese in America into the following five ethnic subcategories: (1) The previously-mentioned first-generation “Issei” — who are the original Japanese migrants to America prior to the Second World War; (2) The New Issei — these are post-War Japanese migrants to America; (3) The Nisei — The 2nd generation of migrants from Japan to the U.S.; (4) The Sansei — 3rd generation Japanese migrants to Americas; and (5) The Kibei — Japanese-American persons born in America but educated in their ancestors’ homeland (Yamada, 2001). “Shame” and “Sekentei” are two unique concepts of Japan’s culture. The latter may be described as dignity, social reputation, or appearance in public or among community members (Asai & Kameoka, 2005, p.114). The Japanese are extremely self-conscious when it comes to how others judge their conduct. For example, neighbors or kin monitor a family for how well it takes care of its aged members. Due to sekentei, familial problems and challenges generally remain within the family. The Japanese aren’t a community comfortable with seeking external assistance with their family. Kameoka and Asai (2005) have revealed that sekentei promotes social service underutilization by caregivers in Japanese households.

While all the aforementioned subgroups are considered “Japanese-American,” they all have their own distinctive features, arising from their unique socialization and history (McLaughlin, 2002). Of the above subdivisions, elderly from the first two clusters significantly differ not only from one another, but from the remaining subgroups as well. They originally brought the customs and traditions of Japan to the U.S. and they experienced considerable challenges when attempting to adjust to American society, owing to cultural and linguistic variations (Sorocco, 1998). Strong familial support in the Japanese-American community originates from the filial piety tradition — a Confucian influence. Familial piety’s essence may be explained using the Japanese words “on” (duty between people) and “ko” (one’s responsibility to one’s parents) (Sorocco, 1998; McLaughlin, 2002). The words do not merely imply children’s duty or obligations towards parents. Rather, they have implicit meanings of respect towards, appreciation of, and obedience towards, parents (Sorocco, 1998; McLaughlin, 2002).

Asian cultural norms, values, and beliefs: Taking into account all present environmental changes affecting caregivers, ethnic/racial minority group caregivers are particularly challenged when keeping to their native cultural norms, values, and beliefs when delivering care to their aged family members. In specific, among the Asian-American community, a strong intergenerational caregiving custom exists, and adherence to the cultural ‘filial piety’ principle — in which adult children take up the responsibility of tending to their elderly parents — is required (Takamatsu, 2002). “Filial piety” originates in China from the ethical and philosophical system of Confucianism. Chinese-American family caregivers stress this value as well as the value of familial harmony (Yamada, 2001). These Asian cultural ideals characteristically interpret the role of the caregiver with regard to the filial duty to tend to older members of the family, and hence, demonstrate respect for their authority and worthiness. Owing to the high regard given to these cultural standards and ideals, ethnic/racial minority caregivers limit their utilization of the formal services available, when carrying out their caregiving duties (Yamada, 2001).

Cultural facets unique to Japan: The culture of Japan comes under the category of “shame cultures,” as compared to western “guilt cultures” (Sato, 2015). A true shame culture will depend on outside sanctions for ethical behavior, rather than on internalized views of sin (like guilt cultures). Shame results from criticism directed as us by others. In this connotation, when any Japanese individual fails at exhibiting proper behaviors defined under their native social rules or cultural standards, or does not succeed in fulfilling his/her workplace responsibilities or requirements, it is regarded as shame (“haji”) (Sato, 2015, p. 47). Therefore, Japanese are typically highly self-conscious when it comes to their public appearance and the way others view them. Applying this to the family caregiving context, Japanese caregivers are reluctant to employ outside services, which may signify their failure to carry out their responsibility or duty of providing suitable care to their family’s care recipients.

Studies reveal that familial bonds have a central part to play in elderly Japanese’s social support framework (Yamada, 2001). Results from interviews conducted at participant homes depict that while support dependability and sufficiency levels differ for different members of the family, elderly Japanese expect to receive family support ranging from emotional to instrumental. Family relationships in the Japanese culture also encompass what is labeled by Ishizuka as “psycho-cultural price” — an individual’s own unique psychological price founded on his/her internalized cultural values system (Yamada, 2001, p. 19). The Japanese formal service underutilization trend is linked to their elderly members’ self-reliance — with significant self-pride, an individual will be inclined to depend on him/herself. This inclination when practiced effectively will become ‘ability’, which is a positive trait that returns as something to be proud of, to the individual in question. In the Japanese culture, self-reliance doesn’t essentially imply that an individual will seek to depend on none but him/herself. Rather, it partly implies fulfilling all of one’s needs in the family itself and not resorting to outside assistance (Yamada, 2001).

A majority of elderly New Issei and Issei, who speak Japanese as their first language, have experienced trouble with the U.S. healthcare system, owing to the linguistic barrier they come up against. They have a narrow choice when it comes to availing themselves of public services, on account of inaccessibility caused by these linguistic barriers. Furthermore, they have to depend on their kith and kin who can speak or understand English (NAPCA, 1998). A NAPCA (National Asian Pacific Center on Aging) report indicated that a highly critical issue elderly Pacific Islanders and Asians encounter is underutilization of human services and healthcare, owing to cultural and linguistic barriers (1998). As per NAPCA estimates, more than thirty percent of aged Pacific Islanders and Asians reside in families where not a single adult member (currently) speaks English — this is probably what limits their public service usage. Additionally, it was projected that in 2000, sixty percent of aged Pacific Islanders and Asians would only have limited English speaking proficiency (NAPCA, 1998).

The aged Japanese participants of Ishizuka’s research wished to maintain their native language and other cultural values. When they were posed the question of what, in their view, must service providers know, forty percent of participants stated it was the ability to understand and/or speak in their native language (Yamada, 2001). Lastly, some healthcare ethical facets of Japanese culture apparently differ from those of the American culture. For the Japanese, for instance, patients as well as their families traditionally tend to trust the suggestions and recommendations of their doctors easily. In some instances, patients are completely reliant on their physicians’ opinions and allow them to decide on their treatments. A second cultural tradition is: doctors need not talk over the exact prognosis or diagnosis with the patient, in case of end-of-life or terminal illness-related decision-making. The physician, patient, and his/her family members reach an “understanding” with regard to the practice (Yamada, 2001). Normally, the physician only informs family members of the precise diagnosis/prognosis. This practice’s goal is avoiding potential psychological decline of the patients into desolation or dread relating to the diagnosis’ acceptance (Yamada, 2001).

1.7. Japanese and “local” identity in the State of Hawaii

Japanese history of migrating to Hawai’i dates back to 1868, when 148 Japanese migrants first set foot on the land (Sato, 2015; Saldov et al., 1998). Drawn by the economic opportunities provided by Hawaii, they migrated to the island as contract plantation laborers. The boom in Hawaii’s sugar industry especially brought several Japanese to Hawaiian shores. In the year 1910, Hawaiian territory housed four times the number of Japanese housed by contiguous U.S.A. The Japanese ethic group continued growing, and Japanese accounted for 43% of Hawaii’s population by 1920 (Sato, 2015, p. 48).

In view of the above demographic status, the cultural experiences of Japanese migrants to Hawai-i vastly differed from those of Japanese migrants living in contiguous America (Sato, 2015; Saldov et al., 1998). A key difference was the emergence of Hawaiian “local” identity, whose historical origins lie in the period before the Second World War. This “local” Hawaiian identity was reinforced during sugar plantation worker strikes and the 60’s tourism and economic development. As the State has historically been under the influence of external control and authority politically as well as economically, Hawaiians had to differentiate themselves from foreigners and tourists (Sato, 2015). A “local” identity was their only sound option. This “local” status still represents Hawaiians’ collective identity in today’s world — they are characterized by commitment to and appreciation of the Pacific islands, their cultures, peoples, and lifestyles, which are considered to be at risk from outer forces of change and progress (Sato, 2015, p.48).

1.1. Japanese Language in American Japanese’s elderly care

English is the popular and official language in the U.S. but, the first generation of immigrants from Japan, the Issei and the Nisei, speak Japanese with English as a second language. The later generations of Japanese-Americans have English as the first language and knowledge of Japanese highly scattered within these later generations (NAPCA, 1998). In the state of Hawaii, Japanese is the most common language used by the Nikkei, which is probably because of the fact that, the group makes about one fifth of the population of the state, and the cultural influence of the Japanese people is deeper as compared to other states in the U.S. (McLaughlin, 2002; NAPCA, 1998). In addition to being the major language spoken by Japanese-Americans, it is also being studied not only by the later Japanese generations but also across ethnicities. Japanese subtexts are used in signs for example, in public transportation, and in civic facilities. It is therefore no wonder that language is used as the primary language of communication in facilities that provide elderly care that targets Japanese-Americans.

As argued by Szczepura (2005), linguistic competence is a major description of an organization’s as well as its personnel capacity to communicate effectively. For an elderly care facility targeting Japanese-Americans with Japanese is their first language, ability of the facilities personnel to speak fluent Japanese is an indication of the ability to convey information in a manner that is easy to understand by their clients/patients. Anderson et al. (2003) argue that, linguistic competency is one of the guarantees for culturally relevant treatment. For Japanese elderly persons seeking Japanese oriented care, the primary concern is care that is culturally relevant and language is a major ingredient in the determination of culturally relevant care.

The other reason why Japanese is used for Japanese elderly patients is to ensure equitable access to care for the minority ethnic population. Szczepura (2005) argues that to improve on access to care for such an ethnic minority, it is important to provide personnel that is not only bilingual, but also bicultural, provide translation services where necessary, and have all care materials developed and tested for specific cultural and linguistic groups. In general, using Japanese language to communicate to elderly Japanese-Americans goes to appeal to their cultural liking and improves on desire to seek elderly care as compared to family care which is economically expensive (Anderson et al., 2003) at both individual family and state levels.

1.8. Japanese-American end-of-life (EOL) issues

A fairly small body of literature is available on the topic of Japanese-American patients’ EOL issues. An almost-30-year-old survey conducted in Los Angeles had subjects from the Japanese-American ethnic minority group (multiple generations, right from 1st to 3rd generation Japanese-Americans) and 3 other such groups. The survey included questions on their rites and viewpoints with regard to dying and death. In discussing this ethnic minority’s background, researchers observed that the Issei exhibited a highly composed acceptance of suffering and death as phenomenological realities; their level of acceptance is in stark contrast to the acceptance level depicted by the Sansei (Nakao, 2009; Takamatsu, 2002). In researchers’ view, such acceptance denotes active coping — Japanese-Americans attempt to adjust to an inevitable reality, instead of attempting to get used to one that is external. Such orientation applies to other facets of the Issei lifestyle as well, including their low resistance to relocation of almost the entire ethnic subgroup in the course of the Second World War, and other types of racial/ethnic persecution they experienced for a long period (Nakao, 2009). The research work further identified additional generational or age differences in Japanese-American behavior acculturation. For instance, most Issei participants of the survey spoke Japanese, practiced Buddhism, and adhered to their homeland’s rituals and practices. All these characteristics were found less frequently among the succeeding generations, particularly the 3rd-generation Sansei, who had minimal touch with their religion, and low adherence to Japanese rituals, in comparison to their elders (Nakao, 2009; Takamatsu, 2002).

A research work on Japanese-Americans and three other Hawaiian ethnic groups revealed that a consensus existed among them that it was good to prepare oneself for death, supported by their religious (Buddhist) teachings, which urge followers to speak about and prepare for death. The Japanese-American subjects of the study comprised of 6 Nisei with English as their primary language, a Buddhist cleric, and an ex-director of a social services organization (Nakao, 2009). Participants in focus group discussion revealed their belief that a majority of Japanese-Americans consider advance directives valuable and have completed documents of this sort. With regard to organ donation, participants believed unwillingness to do so arose from the reluctance to despoil one’s body — traditionally regarded as sacred and a gift given to them by their ancestors which must, therefore, be returned undamaged. Nevertheless, participants acknowledged the evolution of practices and views over time. According to them, the present-day Japanese-American population was drifting away from traditional Buddhist customs, and this indicates members’ behavioral and attitudinal changes, in addition to internal differences arising from acculturation (Nakao, 2009).

Lastly, a cross-cultural and cross-national survey that included elderly Japanese-American and Japanese participants discovered that, based on acculturation levels, attitudes toward EOL care differed. For instance, Japanese-Americans who spoke English exhibited more encouraging attitudes towards care withdrawal and planning for advanced care compared to those who spoke Japanese. Furthermore, the desire to get to know bad news remained consistent with greater acculturation (Nakao, 2009). Those who were less acculturated expected their family to be the first recipients of any bad news; the family would subsequently discuss the matter and decide on whether to inform the patient or not (Nakao, 2009). This indicates that the ethnic group supports family-oriented model of decision-making.

1.8.1. Issues arising in the care of Japanese-American elderly

Poor care of terminally ill patients is a key concern across the aging U.S. population. Latest empirical research works have ascertained the complex needs of aged American EOL care patients and their family members from different backgrounds. As a response to emergent and diverse needs, empirical research has corroborated social work’s potential in significantly contributing to improvement of American EOL and palliative care. For instance, nursing homes’ social workers depicted high involvement in discussing advance directives, issues with directive implementation, and wide disparities in their comfort levels when it comes to treatment problems (Nakao, 2009, p.45). Moreover, in clinical settings, patient-doctor (also, doctor -family and doctor- decision-maker/caregiver) conflicts commonly occur with respect to treatment choices for the terminally ill. Hence, ethics committee consultants are widely approached with such issues (Nakao, 2009). Lastly, numerous other situations and settings may be seen where EOL problems become especially pertinent (e.g., social services, residential settings, and hospices), where aged patients may be driven by social workers across EOL decisions and advance directives (Nakao, 2009).

Scholars in the field of social work have increasingly acknowledged their field’s growing role in EOL-related matters and their implications for the culturally-sensitive organization. They have methodically identified a total of 11 key priority areas as a nationwide social work studies agenda, declared to eventually inform policy, professional education, and direct practice (Nakao, 2009), which are as follows: 1) Care continuity, fragmentation, transition, and gaps; 2) Healthcare disparities; 3) Policy-practice relationship and funding; 4) Family and individual care experiences and needs; 5) Mental health services and concerns; 6) Service and care quality; 7) Communication; 8) Family conferencing, caregiver assistance, and decision making; 9) Symptom and pain management; 10) Grief and mourning; and 11) Development of curriculum, training, and appraisal. Researchers highlighted the fact that, across all key areas, research into social work must deal with patients and families hailing from different backgrounds, and must focus on different attributed and attained social status factors/variables, such as ethnicity and race. These key areas underscore social workers’ central role and their necessity in the present day, and their knowledge requirements with regard to EOL matters.

1.9. A Japanese-American Model of Care

As per the 2000 U.S. Census report, just as Japan is globally the world’s oldest ethnic group, so are the Japanese-Americans in the U.S. — about 20% of Japanese-Americans are aged above 65 years. This statistic in case of the mainstream American population is 10%. Therefore, an analysis of this ethnic group, already in the midst of its “age wave,” may be able to offer valuable insights for predicting and tackling aging-related problems in the overall American population (Belli, 2013). USA’s ethnic communities present a remarkable third comparison point between the U.S. and their countries of origin (Belli, 2013). Although Japanese-Americans’ response to their huge aging population is effective within the U.S. long-term and health care systems, it has several similarities to that of Japan. As a small-scale version of what the imminent aging America will appear like, Japanese-Americans’ model can explain how a community adjusts itself to its older generation’s needs (Belli, 2013).

America’s biggest healthcare organization specific to elderly Japanese-Americans — Keiro Senior HealthCare — has been delivering culturally-sensitive healthcare to South California’s Japanese-American population for over half a century, operating within the U.S. healthcare structure’s bounds (Keiro Senior HealthCare, n.d.). Apart from taking care of its residents, the organizations also offers continuous assistance to familial caregivers and individuals whose family members might ultimately require care and support (Keiro Senior HealthCare, n.d.). Japanese-Americans’ health indicators are more similar to those of America, than of Japan. This indicates that lifestyle influences contribute more to development of chronic ailments than genes alone. As per the California Health Interview Survey (CHIS) of 2009, America’s diabetes prevalence is one among the highest worldwide (8.3%), slightly less than Japanese-Americans’ almost-ten-percent figure.

Although the obesity rate for Japanese-Americans (12.8%) is substantially lower than America’s national rate, CHIS 2009 indicates that it still constitutes one among the highest rates among the United States’ Asian ethnic communities (Belli, 2013). As a response to the above trends, Keiro Senior HealthCare established its “Institute for Healthy Aging” for dealing with elderly Japanese-Americans’ needs. All services endeavor to fulfill no less than one out of the following eight wellness dimensions: physical, emotional, spiritual, financial, occupational, social, environmental, and intellectual. By means of evidence-based initiatives, community partnerships, and healthy living seminars, the Institute, backed by community sponsors and volunteers, provides aged people with resources necessary for leading a healthy (genki) life. While Keiro’s services might continue functioning as a “safeguard” for the weakest of aged people, its future goal is supporting the Japanese-American population to grow old with confidence (Keiro Senior HealthCare, n.d.).

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